TABLE OF CONTENTS: Preface ix
Acknowledgments xxi
Reading Notes xxv
CHAPTER ONE: Complexities in Control 1
The Limits of Regulation and Self-Regulation 5
The Tradeoff Quandary 9
Concerns, Commitments, and Control 17
The Nuclear Connection: Naval and Corporate Orders 23
The Cycle of Self-Improvement: The Event Review System 28
CHAPTER TWO: Arrow Station: A Leaking Valve in Containment 35
An Account of a Valve Repair Effort 35
Event Inquiries 44
The Teams' Reports 48
Insights and Excursions 59
The Parts Template 88
CHAPTER THREE: Bowie Station: A Reactor Trip and a Security Lapse 98
An Account of an Automatic Reactor/Turbine Trip 98
Trip Event Review Team Report 100
Insights and Excursions 103
An Account of a Security Lapse 120
Mis-Authorization Event Review Team's Report 123
Insights and Excursions 125
The Two Events: Tangential or Essential? 142
CHAPTER FOUR: Charles Station: Transformer Trouble 144
An Account of a "Significant Near-Miss"
on a Generator Step-up Transformer 144
Witnessing "A New Find" 151
Team Reports 154
The Reception of the "Organizational Effectiveness"
Team Report 158
Insights and Excursions 162
CHAPTER FIVE: Logics of Control 196
Three Logics of Control Culture 198
An Infrastructure of Conundrums 203
Control in Real Time 209
Doubt, Discovery, and Interpretation 213
Words, Meanings, and Deeds 217
Standing in the Way: A System of Claims 224
Crystallizing the Difference: Numbers and Values 230
Objective and Subjective, Technical and Substantive 235
Certainty and Ambiguity, Doubt and Discovery 237
CHAPTER SIX: Intellectual Capital for Regulation and Self-Regulation 240
Controlling and Coordinating Knowledge 242
The Scope of Event Reviews 248
"Maintenance Is Going to Save You" 257
"Levels of Maturity" 262
Re-Imagining the Culture of Control
in the Nuclear Power Industry 266
From Functions to Meanings:
A Second Axis for Risk-Reduction 270
Into the Next Half-Century 276
APPENDIX ONE: Senior Management Group at Overton Station 283
APPENDIX TWO: Nuclear Power Plant Modes of Operation or Shutdown 286
APPENDIX THREE: Study Description 288
Notes 289
Bibliography 325
Index 367
Return to Book Description File created: 4/18/2012 | 
